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Name:

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Subscriber's Name:

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Relationship to patient:

Subscriber's Date of Birth:

Subscriber's Address (if different than above)

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Emergency Contact Person​​​​​​​

I grant permission to share my medical information with this contact.
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Privacy Policy

I hereby acknowledge that I have received a copy of the Lori A. Heyler, OD LLC ‘s Notice of Information Practices and I understand that the notice describes how this office uses and discloses my medical and billing information.
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Signature:

Date:

Assignment of Insurance Benefits​​​​​​​

I hereby authorize payment directly to Lori A. Heyler, OD LLC from my vision plan and/or health insurance. I understand that I am responsible for charges not covered by my insurance.
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Signature:

Date:

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